Dermatology

Question 1

Clinical presentation of measles

Answer 1

Symptoms start 10 – 12 days after exposure, with fever (>40 classically) , coryzal symptoms and conjunctivitis
Koplik spots are greyish white spots on the buccal mucosa, appear 2 days after fever
rash starts on the face, classically behind the ears after fever , erythematous, macular rash with flat lesions.

Question 2

Measles management

Answer 2

self resolving after 7 – 10 days of symptoms
Children should be isolated until 4 days after their symptoms resolve.
notifiable disease
Vitamin A for children in developing countries or that are malnourished or under 2 years old

Question 3

Clinical presentations chicken pox

Answer 3

widespread, erythematous, raised, vesicular (fluid filled), blistering lesions
Once they scab, no longer infectious (usually around 5 days after the rash appears)
Fever is often the first symptom
Itch
General fatigue and malaise

Question 4

Chicken pox treatment

Answer 4

usually a mild self limiting condition
Aciclovir may be considered in immunocompromised patients, adults and adolescents over 14 years presenting within 24 hours, neonates or those at risk of complications
itching can be treated with calamine lotion and chlorphenamine (antihistamine)
Patients should be kept off school and avoid pregnant women and IC patients until all the lesions are dry/crusted over, usually around 5 days after the rash appears

Question 5

Clinical presentation of rubella

Answer 5

milder erythematous macular rash compared with measles. spreads face downwards but classically, the rash spares the limbs, as opposed to the rash of measles
mild fever, joint pain and a sore throat. lymphadenopathy

Question 6

Rubella management

Answer 6

supportive, condition is self limiting. notifiable disease.
Children should stay off school for at least 5 days after the rash appears
should avoid pregnant women.

Question 7

congenital rubella syndrome triad

Answer 7

deafness, blindness and congenital heart disease.

Question 8

Roseola Infantum

Answer 8

caused by human herpesvirus 6
commonly seen in children between 6 months and three years
presents 1 – 2 weeks after infection with a high fever (up to 40ºC) that comes on suddenly, lasts for 3 – 5 days and then disappears suddenly
coryzal symptoms
When the fever settles, the rash appears for 1 – 2 days.
mild erythematous macular rash across the arms, legs, trunk and face, not itchy

Question 9

Mx Roseola Infantum

Answer 9

Children make a full recovery within a week and do not generally need to be kept off nursery if they are well enough to attend

main complication to be aware of is febrile convulsions due to high temp

Question 10

Clinical presentation Parovirus

Answer 10

fever rash and runny nose diarrhoea
lace-like rash in the trunk and arms, slapped cheek appearance, more in women and adults.
In adults, Parvovirus B19 presents with arthralgias.

Question 11

Clinical features of Haemolytic uraemic syndrome (HUS)

Answer 11

haemolytic anaemia, an AKI and thrombocytopenia
associated with oliguria (very low urine output) and signs of anaemia. often presents in a child with recent diarrhoea

Question 12

Aetiology of Idiopathic thrombocytopenic purpura

Answer 12

type II hypersensitivity reaction. It is caused by the production of antibodies that target and destroy platelets. This can happen spontaneously, or it can be triggered by something, such as a viral infection.

Question 13

Epidemiology of Idiopathic thrombocytopenic purpura

Answer 13

children under 10 years old. Often history of a recent viral illness. onset of symptoms occurs over 24 – 48 hours:

Question 14

Management of Idiopathic thrombocytopenic purpura

Answer 14

(platelets below 10):
Prednisolone
IV immunoglobulins
Blood transfusions if required
Platelet transfusions only work temporarily
Rituximab for resistant ITP
Azathioprine.
Consider splenectomy

Question 15

Cause of impetigo

Answer 15

1.staphylococcus aureus (bulbous impetigo)
2.streptococcus pyogenes

Question 16

Non-bullous impetigo

Answer 16

nose or mouth region
exudate from the lesions dries to form a “golden crust”
Topical fusidic acid can be used to treat localised
antiseptic cream (hydrogen peroxide 1% cream)
flucloxacillin is used to treat more wide spread/severe forms

Question 17

Impetigo advice

Answer 17

Advice about not touching or scratching the lesions, hand hygiene and avoiding sharing face towels and cutlery. They need to be off school until all the lesions have healed or they have been treated with antibiotics for at least 48 hours.

Question 18

Bullous impetigo

Answer 18

always caused by the staphylococcus aureus
1 – 2 cm fluid filled vesicles
grow in size and then burst, forming a “golden crust”.
lesions can be painful and itchy
more common in neonates and children under 2
may be feverish and generally unwell
usually flucloxacillin to treat

Question 19

Epidemiology of Staphylococcal scalded skin syndrome

Answer 19

usually affects children under 5 years

Question 20

Clinical presentation of Staphylococcal scalded skin syndrome

Answer 20

starts with generalised patches of erythema.
often causes erythroderma
skin looks thin and wrinkled, followed by the formation of fluid filled blisters called bulla
desquamation (peeling of the epidermis) and positive Nikolsky sign (gentle rubbing of the skin causes it to peel away)
Perioral crusting/fissuring is common, oral mucosa is usually unaffected unlike in TEN
Systemic symptoms

Question 21

Staphylococcal scalded skin syndrome (SSSS) Mx

Answer 21

IV antibiotics e.g. vancomycin if methicillin resistant staphylococcus aureus is suspected
Fluid and electrolyte balance
Emollients and dressings to skin
Analgesia
When adequately treated, children usually make a full recovery without scarring.
Recovery is usually within 5-7 days

Question 22

Nikolsky sign is positive in

Answer 22

SSSS, TEN and pemphigus vulgaris.

Question 23

Bullous pemphigoid

Answer 23

autoimmune condition causing sub-epidermal blistering of the skin
deep, tense blisters. itchy
Unlike pemphigus, oral mucosa is rarely affected
Nikolsky sign is negative

Question 24

Bullous Pemphigoid management

Answer 24

very potent topical corticosteroids eg Dermovate (clobetasol propionate 0.05%).

Question 25

Pemphigus vulgaris

Answer 25

autoimmune disease mucosal ulceration is common skin blistering - flaccid, easily ruptured vesicles and bullae. Lesions are typically painful but not itchy Nikolsky positive

Question 26

Aetiology of Scarlet fever

Answer 26

group A streptococcus infection,usually tonsillitis, eg streptococcus pyogenes

Question 27

Complications of scarlet fever

Answer 27

otitis media rheumatic fever acute glomerulonephritis invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis)

Question 28

Clinical presentation of Scarlett fever

Answer 28

red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards. Patients can have red, flushed cheeks. Systemic symptoms,Sore throat, Strawberry tongue ( red and bumpy), Cervical lymphadenopathy

Question 29

Management of Scarlett fever

Answer 29

phenoxymethylpenicillin (penicillin V) for 10 days. notifiable disease Children should be kept off school until 24 hours after starting antibiotics.

Question 30

Aetiology of warts

Answer 30

Infection of epidermal cells with DNA human papilloma virus

Question 31

Aetiology of Molluscum contagiosum

Answer 31

molluscum contagiosum virus, a type of DNA poxvirus.

Question 32

NICE criteria eczema/atopic dermatitis

Answer 32

itchy skin + 3/5 of: Visible flexural eczema* History of flexural eczema* History of dry skin in last 12 months History of asthma or allergic rhinitis (or history of atopy in 1st degree relative if <4 years) Onset of signs/symptoms <2 years old (do not use if <4 years old) *or on the cheeks/extensors in children <18 months

Question 33

What is Eczema herpeticum

Answer 33

dermatological emergency caused by a disseminated HSV infection or varicella zoster virus due to impaired skin protection as a result of atopic dermatitis. It results in a monomorphic vesicular rash which can ulcerate and crust. There may be systemic effects, such as fever. Diagnosis can be confirmed with a swab + Tzanck test. Treatment is with IV aciclovir

Question 34

Drug triggers of psoriasis

Answer 34

B blockers, Anti malarial, Lithium, Indomethacin/nsaids (BALI)

Question 35

Triggers of Guttate psoriasis

Answer 35

streptococcal throat infection, stress or medications.

Question 36

What is Auspitz sign

Answer 36

refers to small points of bleeding when plaques are scraped off in psoriasis

Question 37

nail features of psoriasis

Answer 37

nailed pitting , onycholysis (nail bed separation), subungal hyperkeratosis

Question 38

Mx psoriasis

Answer 38

Topical steroids Topical vitamin D analogues (calcipotriol/dovonex) Topical dithranol/vit a analogue Tazarotene/coal tar Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis Topical calcineurin inhibitors (tacrolimus)] Systemic therapies: Biologics

Question 39

Topical steroids potency

Answer 39

Help every budding dermatologist Mild- hydrocortisone Moderate- eumovate Potent- betnovate Very potent -dermovate

Question 40

open comedone

Answer 40

Blackhead

Question 41

Cause of Hand foot and mouth disease

Answer 41

coxsackie A virus. Incubation is usually 3 – 5 days.

Question 42

Clinical presentation of hand foot and mouth disease

Answer 42

starts viral URT symptoms. After 1 – 2 days small mouth ulcers, followed by blistering red spots across the body. Especially on the hands, feet and around the mouth. Painful mouth ulcers, particularly on the tongue The rash may be itchy

Question 43

Mx hand foot and mouth disease

Answer 43

supportive, with adequate fluid intake and simple analgesia resolves spontaneously without treatment after a week to 10 days highly contagious, but if children are well can still go to school

Question 44

Clinical presentation of Erythema nodosum

Answer 44

red, inflamed, subcutaneous nodules across both shins. nodules are raised, can be painful and tender. Over time the nodules settle and appears as bruises.

Question 45

Clinical presentation Erythema Multiforme

Answer 45

widespread, itchy, erythematous rash. Target lesions are red rings within larger red rings, with the darkest red at the centre, similar to a bulls-eye target. can cause a sore mouth (stomatitis). Can cause systemic symptoms

Question 46

Causes of Erythema Multiforme

Answer 46

herpes simplex virus (causing coldsores) mycoplasma pneumonia penicillin use

Question 47

Treatment for cellulitis

Answer 47

flucloxacillin Clarithromycin, erythromycin (in pregnancy) or doxycyline is recommended in patients allergic to penicillin. penicillin is the antibiotic of choice for group A streptococcal infections. severe cellulitis should be offered co-amoxiclav, cefuroxime, clindamycin or ceftriaxone.

Question 48

Treatment for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)

Answer 48

medical emergencies supportive care is essential, including nutritional care, antiseptics, analgesia and ophthalmology input Treatment options include steroids, immunoglobulins and immunosuppressant medications

Question 49

Clinical presentation of Stevens-johnson syndrome/TEN

Answer 49

start with non-specific symptoms of fever, fatigue, cough, sore throat, sore mouth, sore eyes and itchy skin. develop a purple or red rash that spreads across the skin and starts to blister. skin starts to break away and shed leaving the raw tissue underneath. Pain, erythema, blistering and shedding, inc lips/mucous membranes Eyes can become inflamed and ulcerated It can also affect the urinary tract, lungs and internal organs.

Question 50

Scabies clinical presentation

Answer 50

can take up to 8 weeks for any symptoms or rash to appear after the initial infestation itchy small red spots, possibly with track marks where the mites have burrowed between the finger webs, but it can spread to the whole body

Question 51

Treatment for scabies

Answer 51

permethrin cream,repeated a week later to kill all the eggs Oral ivermectin if difficult to treat or crusted scabies Crotamiton cream and chlorphenamine at night can help with the itching all household and close contacts should also be treated

Question 52

Treatment for headlice

Answer 52

Dimeticone 4% lotion can be applied to the hair and left to dry for 8 hours then washed off. Process repeated 7 days later to kill any head lice that have hatched since Special fine combs can be used to systematically comb the nits and lice out

Question 53

Vitiligo

Answer 53

loss of melanocytes in the epidermis basal layer presents before 30y mainly associated with autoimmune disease depigmented skin can follow pregnancy, severe sunburn, trauma or a period of emotional stress

Question 54

Management of vitiligo

Answer 54

Check for other autoimmune disease Cosmetic camouflage Phototherapy Ditrhanol Topical tacrolimus Sunscreen Topical therapies (e.g. steroids, calcineurin inhibitors) Systemic steroids (e.g. prednisolone): may be needed for widespread disease. Systemic immunosuppression (e.g. methotrexate)

Question 55

Non melanoma skin cancer includes

Answer 55

•Basal cell carcinoma •Squamous cell carcinoma

Question 56

What is Basal cell carcinoma

Answer 56

slow-growing, locally invasive, malignant epidermal (basal layer) keratinocyte skin tumour, rarely metastasize, commonest form of skin cancer

Question 57

Clinical presentation of basal cell carcinoma

Answer 57

irregular pink / skin-coloured lesion; commonly on the face or neck. T - Telangiectasia(small blood vessels). U - Ulceration R - Rolled edges P - Pearly edge

Question 58

What is Bowen's disease

Answer 58

intra-epidermal (in situ) squamous cell carcinoma of the skin. The rate of transformation in to invasive squamous cell carcinoma (SCC) is approximately 3%.

Question 59

Acitinic keratosis

Answer 59

often treated because it might turn into squamous cell skin cancer.1 SCC per 1000 actinic keratoses

Question 60

Mx Bowen disease/acitotic keratosis

Answer 60

cryotherapy or topical creams or gels such as fluorouracil (5-FU), imiquimod, or diclofenac. - to destroy the affected area of the epidermis, the outermost layer of the skin Other localized treatments (photodynamic therapy, laser surgery, chemical peeling) or types of surgery (shave excision, curettage and electrodesiccation

Question 61

What is squamous cell carcinoma

Answer 61

locally invasive malignant tumour of the epidermal keratinocytes or its appendages, which has the potential to metastasise

Question 62

What is malignant melanoma

Answer 62

tumour of melanocytes, usually arising in the epidermis

Question 63

melanoma mnemonic 'ABCDE':

Answer 63

• Asymmetric shape • Border Irregular • Colour Variegated • Diameter greater than 6mm • Elevation of a flat mole and evolving lesion

Question 64

Superficial spreading melanoma

Answer 64

Majority F>M common on Lower limbs in young middle age

Question 65

nodular malignant melanoma

Answer 65

M>F Commonest on the trunk , often in people who work outdoors a lot in sunny climate,in young and middle- aged adults

Question 66

Lentigo maligna melanoma

Answer 66

often on the face of an elderly person who has spent many cumulative years in an outdoor occupation

Question 67

aural lentiginous melanoma

Answer 67

palms, soles and nail beds no clear relation with UV exposure elderly

Question 68

Ix melanoma

Answer 68

Dermascopy Biopsy Histological stratification Clark level, Breslow thickness, ulceration and mitotic index may be used to classify the depth of melanoma invasion and / or give an indication of prognosis. skin and lymph node examination. CT or PET-CT for high-risk lesions.

Question 69

what is Breslow thickness

Answer 69

measurement in mm of the distance between the granular cell layer to the deepest identifiable melanoma cell.

Question 70

Mx melanoma

Answer 70

Wide local excision A positive SLNB (i.e. disease deposits found within the sentinel lymph nodes) usually results in lymphadenectomy Electrochemotherapy for patients with locally advanced melanoma. Rx

Question 71

Psoriasis triggers

Answer 71

Skin trauma (koebner phenomenon) Infection: streptococcus, HIV Drugs Withdrawal of steroids Stress Alcohol and smoking cold/dry weather

Question 72

Mx acne

Answer 72

Topical benzoyl peroxide Topical retinoids Topical antibiotics Oral antibiotics such as lymecycline Oral contraceptive pill - Co-cyprindiol (Dianette) Oral retinoids for severe acne (i.e. isotretinoin)

Question 73

Erythema nodosum is associated with

Answer 73

chronic disease: IBD,sarcoidosis, Cancer: lymphoma, leukaemia, Infections: streptococcal throat, gastroenteritis, mycoplasma pneumonia, tb medication: OCP, NSAID Pregnancy

Question 74

Cellulitis vs Erysipelas

Answer 74

Cellulitis describes inflammation of the skin and deep subcutaneous Erysipelas is an acute superficial form of cellulitis and involves the dermis and upper subcutaneous tissue .has well defined, raised red border

Question 75

Microbiological cause of cellulitis

Answer 75

typically due to infection by Streptococcus pyogenes or Staphylcoccus aureus (gram +ve)

Question 76

Necrotising fasciitis

Answer 76

life-threatening infection of the subcutaneous soft tissue, with spread along the fascial planes but not the underlying muscle

Question 77

Most necrotizing fasciitis caused by

Answer 77

group A streptococci that is streptococcus pyogenes.The bacteria release toxins which damage the tissue.

Question 78

Erythroderma

Answer 78

dermatological emergency where there is widespread erythema affecting >90% of the skin surface

Question 79

Causes of erythroderma

Answer 79

commonest cause of erythroderma is exacerbation of a pre-existing skin condition Drug allergies Idiopathic Sezary syndrome

Question 80

Mx erythroderma

Answer 80

supportively with fluids, emollients and by treating the underlying disease wet wraps to maintain moisture in skin Stop offending drugs Topical eumovate (could consider oral steroid course if severe) to relieve inflammation Swabs for bacteriology and virology to look for evidence of overlying infection

Question 81

lichen planus is characterised by the 6 Ps:

Answer 81

Purple,violaceous Pruritic (itchy) Polygonal (multiple sites) Planar (flat-topped) Papules/plaques rash is usually interspersed by white lacy lines, called Wickham's striae, can't be wiped off, often in oral lichen planus

Question 82

Lichenoid eruption

Answer 82

typically occurs 2 months after starting a medication presents similarly to lichen planus, although more commonly affects the trunk and Wickham striae are usually absent. Additionally lichenoid eruptions do not usually affect the oral mucosa

Question 83

Pityriasis rosaea

Answer 83

rash which often occurs after an upper respiratory tract infection and is thought to have a viral cause (HHV 6/7) herald patch - a single, large, discoid (coin-shaped), erythematous patch days later a widespread rash appears across the trunk ,'christmas tree' pattern (worse at bottom, better at top) No treatment is required, self resolves

Question 84

Pityrisis/tinea versicolor

Answer 84

Fungal infections caused by malassezia furfur produced pigment skin changes revealed by tanning in the sun topical anti fungal to treat eg ketoconazole shampoo

Question 85

Ringworm/tinea

Answer 85

itchy rash that is erythematous, scaly and well demarcated. There is often one or several rings edge is more prominent and red and the area in the centre is more faint in colour

Question 86

Treatment of tines ringworm

Answer 86

anti-fungal medications Fungal nail infections can be treated with amorolfine nail lacquer for 6 – 12 months. Resistant cases may need oral terbinafine (check LFT first) mild topical steroid can help settle the inflammation and itching. A common combination is miconazole 2% and hydrocortisone 1% cream (Daktacort). Simple advice should be given to help recovery, prevent spread and avoid recurrence

Question 87

Layers of skin

Answer 87

stratum basal( deepest layer) stratum spinosum Stratum granulosum (stratum lucidum) Stratum corneum (most superficial)

Question 88

wound healing stages

Answer 88

haemostasis inflammation proliferation remodelling

Question 89

Microbiological cause of cellulitis

Answer 89

typically due to infection by Streptococcus pyogenes or Staphylcoccus aureus (gram +ve)

Question 90

Acitinic keratosis

Answer 90

often treated because it might turn into squamous cell skin cancer.1 SCC per 1000 actinic keratoses

Question 91

Petechiae

Answer 91

small (< 3mm), non-blanching, red spots on the skin caused by burst capillaries

Question 92

Purpura

Answer 92

larger (3 – 10mm) non-blanching, red-purple, macules or papules created by leaking of blood from vessels under the skin

Question 93

Macule

Answer 93

Flat lesion <1cm

Question 94

Patch

Answer 94

Flat lesion >1cm

Question 95

Papule

Answer 95

Small raised lesion (<0.5cm in diameter)

Question 96

Nodule

Answer 96

Solid raised lesion (>0.5cm ) with a deeper component

Question 97

Plaque

Answer 97

palpable scaling raised lesion >0.5cm in diameter

Question 98

Vesicle

Answer 98

raised , clear fluid filled lesion <0.5cm in diameter

Question 99

Bulla

Answer 99

raised , clear fluid filled lesion >0.5cm in diameter

Question 100

Cyst

Answer 100

A nodule consisting of an epithelial lined cavity filled with fluid or semi-solid material

Question 101

Differentials for non blanching rash

Answer 101

Meningococcal septicaemia or other bacterial sepsis Henoch-Schonlein purpura Idiopathic thrombocytopenia purpura Acute leukaemia Haemolytic uraemia syndrome Mechanical Traumatic Viral illness

Question 102

Pyogenic granuloma

Answer 102

reactive overgrowth of capillary blood vessels single, shiny, red nodule of up to 1cm commonly on fingers mostly in children and young adults and in females can cause discomfort and frequent, easy bleeding

Question 103

Cause of Viral warts

Answer 103

caused by human papillomavirus infection

Question 104

Mx viral warts

Answer 104

most resolve spontaneously Immunocompetent: salicylic acid, cryotherapy Immunocompromised: adjuvant topical immunomodulation after debridement and salicylic acid,Oral retinoid for multiple resistant warts

Question 105

Seborrhoeic wart ( basal cell papilloma)

Answer 105

• 40-50s, age, sun exposure • Well defined edge • Warty papillary surface • “Stuck on” appearance

Question 106

Epidermoid and pilar cysts

Answer 106

M>F, 20-30s painless skin lump,may present with discharge of a foul cheese-like material

Question 107

Lipoma

Answer 107

benign tumours of adipose tissue commonly on trunk or proximal limbs soft, mobile, and superficial.

Question 108

Pyoderma gangrenosum

Answer 108

uncommon cause of very painful skin ulceration lower legs may be accompanied by systemic symptoms associated with IBD/RA/SLE, haematological disorders

Question 109

Cause of Hand foot and mouth disease

Answer 109

coxsackie A virus. Incubation is usually 3 – 5 days.

Question 110

Lyme disease dermatological presentations

Answer 110

Erythema Chronicum Migrans (circular target-shaped) Borrelia lymphocytoma - blue patch on the earlobe, nipple or scrotum (common in children) Acrodermatitis chronica atrophicans: blue- red discoloration and swelling at extensor surfaces, may be associated with peripheral neuropathy.

Question 111

Rosacea

Answer 111

30-60, F, pale skin flushing predominantly affecting the convexities of the centrofacial region exacerbated by factors causing facial flushing Ocular rosacea may be characterized by eye discomfort, irritation, tearing, foreign body sensation, dryness, itching, photophobia etc

Question 112

Mx Rosacea

Answer 112

self management skin camouflage service topical brimonidine for persistent erythema topical ivermectin for mild-to-moderate papules/pustules, and the addition of oral doxycycline for moderate-to-severe papules/pustule emollient if skin dry laser therapy for persistent telangiectasia

Question 113

allergic Contact dermatitis

Answer 113

type IV (delayed) hypersensitivity reaction that occurs after sensitization and subsequent re-exposure to a specific allergen or allergens

Question 114

Irritant contact dermatitis

Answer 114

non-immunological inflammatory reaction caused by the direct physical or toxic effects of an irritating substance on the skin — prior sensitisation is not required

Question 115

Toxic shock syndrome and streptococcal toxic shock like syndrome

Answer 115

severe acute illness due to exotoxins produced by specific strains of Staphylococcus aureus or Streptococcus pyogenes

Question 116

Toxic shock syndrome and streptococcal toxic shock like syndrome clinical presentation

Answer 116

Fever, diffuse macular red rash, low blood pressure, and multiple organ involvement Shedding of the skin in large sheets, especially from the palms and soles, is usually seen 1–2 weeks after the onset of illness.

Question 117

Cutaneous features of tuberous sclerosis

Answer 117

Angiofibromas: dome-shaped, firm papules in a butterfly distribution across the face. Ashleaf macules: oval patches of white/hypopigmented skin Shagreen patch: leathery plaque on the sacrum that is dimpled like orange peel Ungal fibromas: smooth, fleshy tumours that grow from the nail folds either around the nail or under the nail